Many studies have shown that higher levels of education are associated with lower HIV risk taking, including a recent analysis of data from 11 countries in sub-Saharan Africa (SSA).(1, 2) However, the causal mechanism by which education results in less risk is not known, since having the basic facts about sexual transmission and a positive attitude towards persons living with HIV/AIDS, are themselves only weakly associated with condom use.

Studies using more direct measures of cognitive skills has have shown links between education, cognition, and health.(3) This study, because it was based on Demographic Health Survey (DHS) data, did not have information on self-efficacy and empowerment, which have also been hypothesized to affect risk behavior and be influenced by education.(4, 5) Education might also influence the socioeconomic environment, in turn playing a role in reducing risk behavior. Many HIV infections occur among discordant couples; thus only non-spousal condom use, though somewhat easily measured, may not be the only risk factor worth exploring.

Objective

To evaluate whether the relationship between higher education and reduced risk behavior, such as increased condom use, could be a result of the effect of education on enhancing higher order cognitive skills, such as health reasoning.

Data obtained from adults who reported sexual activity with multiple partners in the last 12 months were included. Adults who were sexually abstinent or faithful (including faithful polygamists) were excluded. The dependent variable was condom use with a non-spouse during last intercourse (reported among 35% of respondents). Independent variables included last grade in school completed, number of correct HIV knowledge questions or 'facts' (n=7), a composite variable for 'attitudes', and a 'health reasoning' variable based on responses to myths about HIV and sexual transmission. Gender, age, marital status (married/cohabitating or unmarried), residence (rural or urban), country, and economic resources were included covariates. Structural equation models (SEM) were constructed in stages to evaluate the association of formal education to condom use as mediated by 'facts,' 'attitudes,' and 'health reasoning.'

Results

Data from 19,800 adults were analyzed, of whom 35% reported non-spousal condom use during last intercourse. Prior to inclusion of mediating factors, every additional year of education increased the likelihood of condom use by 0.20. Each additional year of education had a significant increase on the likelihood of acquisition of facts (0.19) and positive attitudes (0.43). However, in a full model of information and attitudes mediating the relationship to condom use, there were only weak effects of attitudes (0.10) and facts (0.10) and condom use; this translates to only a 0.02 and 0.04 indirect effect of one year of education on condom use when mediated by these 2 variables, with a direct effect (unmediated) of condom use on education of 0.14. A final model included a 'health reasoning construct' as a third potential mediating factor. The education effect on reasoning (0.56) was greater than either its effect on facts or attitudes. The inclusion of health reasoning in the model reduced the effect of facts and attitudes on condom use to insignificance, while the effect of health reasoning on condom use was high (0.54); this translated to a mediated effect of education on condom use of 0.30. The addition of health reasoning to the model caused the initial direct effect of education on condom use to drop to nearly zero.

Conclusions

Based on these analyses, the authors propose that schooling enhances higher order cognitive skills, such as reasoning and task planning, and that these abilities result in enhanced decision making skills that lead to condom use. In contrast, knowledge about HIV and improved attitudes toward persons living with HIV/AIDS, which can also be acquired through education (or targeted prevention programs), in themselves have a minimal to non-significant effect on condom use.

Quality Rating

This was a good study. However, some incomplete editing of the manuscript and omissions made interpretation difficult. Information on construction of scales for attitudinal variables and health reasoning were not provided. The measures used in the DHS that ask about HIV myths and STDs are only proxies for cognitive skills such as reasoning and task planning.

Programmatic Implications

Primarily targeting acquisition of facts and a positive attitude about HIV/AIDS may be inadequate strategies to effect risk reduction, particularly for those who lack education and reasoning skills. The results from this study argue for spending more effort on improving access to education and improving the quality of public education. In the absence of that, prevention programs should explore methods for target audiences to develop health reasoning skills so they can make use of the prevention messages.

References

Baker D, Collins JM, Leon J. Risk factor or social vaccine? The historical progression of the role of education in HIV and AIDS infection in sub-Saharan Africa. Prospects: Q Rev Comp Educ. 2009;38(4):467-86.